ISSN: 2469-5823 Ingvarsson et al. Int Arch Nurs 2019, 5:119 DOI: 10.23937/2469-5823/1510119 Volume 5 | Issue 1 International Archives of Open Access and Health Care

Original Article Managing Uncertainty in Nursing - Newly Graduated Nurses’ Experiences of Introduction to the Nursing Profession Elina Ingvarsson, BSc, RN1, Josefin Verho, BSc, RN1 and Kristina Rosengren, PhD, RN1,2*

1 Check for Sahlgrenska Academy, Institute of Health and Care Sciences, University of Gothenburg, Sweden updates 2Department of Internal Medicine, Sahlgrenska University , Mölndal, Sweden *Corresponding author: Kristina Rosengren, PhD, RN, Associate Professor, Sahlgrenska Academy, Institute of Health and Care Sciences, University of Gothenburg; Department of Internal Medicine, Sahlgrenska University Hospital, Sweden, ORCID iD: 0000-0002-3221-2062

Abstract Introduction Background: The introduction to nursing, which is the After a minimum of three years of university studies, conversion of theoretical knowledge into practice skills in newly graduated nurses are eager to start working. complex healthcare settings, is emphasized as difficult However, future nurses express anxiety about entering due to patient safety. Therefore, the aim of this study was to describe newly graduated nurses’ experiences of the nursing profession, which is why the introduction introduction to nursing in a medical department (medical, to the nursing profession is important to ensure patient emergency) at a university hospital in western Sweden. safety [1,2]. The current study intends to broaden the Method: A manifest qualitative content analysis with an knowledge regarding this introduction to improve inductive approach was used based on five semistructured newly graduated nurses’ work environment and ensure interviews with newly graduated nurses who work in a a high quality of care. medical department at Sahlgrenska University Hospital in Gothenburg, Sweden. Background Findings: One main category was found, managing A nursing education develops knowledge regarding uncertainty in the nursing profession, which includes three health and well-being and is an art that uses objective subcategories, namely, being humble as a newly graduated nurse, being adaptable as a newly graduated nurse and (quantitative) and subjective (qualitative) perspectives. being a staff member instead of a nursing student. This Theoretical models prepare nursing students to under- category and these subcategories are described in the stand context and behaviors. However, practical wis- results. dom and tacit knowledge grows through experience, Conclusion: The transition from education to registered which is why it is difficult to learn in only a theoretical nurse is a difficult step due to the anxiety that stems from perspective [3,4]. Therefore, theoretical and practical making mistakes regarding limited experience related to the demands and requirements of the job. Therefore, stan- knowledge are required to transform and translate dardized (routines, guidelines) and individualized (expe- nursing studies into clinical settings [5]. The opportu- riences) introductions facilitate patient safety. Moreover, nities for nursing students to participate in a peer men- person-centeredness ensures that every nurse is a capable toring relationship improve nursing, and mentorship person with resources to use in health care, i.e. a partner- helps students to fulfill future professional responsibil- ship within a healthy working environment that transforms novices to experts in nursing. ities by developing skills that improve communication and critical thinking [6]. Moreover, to facilitate future Keywords nurse’s assignments in health care, educators in uni- Introduction, Mentorship, Newly graduated nurse, Supervi- versities and clinical settings need innovative pathways sion, Transition, Person-centeredness, Qualitative content that bring students and clinicians together as team analysis

Citation: Ingvarsson E, Verho J, Rosengren K (2019) Managing Uncertainty in Nursing - Newly Gradu- ated Nurses’ Experiences of Introduction to the Nursing Profession. Int Arch Nurs Health Care 5:119. doi.org/10.23937/2469-5823/1510119 Accepted: March 23, 2019: Published: March 25, 2019 Copyright: © 2019 Ingvarsson E, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Ingvarsson et al. Int Arch Nurs Health Care 2019, 5:119 • Page 1 of 8 • DOI: 10.23937/2469-5823/1510119 ISSN: 2469-5823 members to overcome the gap between theory and medical department (medical, emergency unit) at a practice [4]. Nurse’s had several task, one is preven- university hospital in western Sweden. tative care [7,8]; however, when more care is needed, nursing must be performed in collaboration according Method to the team’s practical, empirical and personal knowl- Settings edge [4,9]. Sahlgrenska University Hospital [17] is one of the The complexity between theory and practice chal- largest workplaces in the county council of Västra lenges newly graduated nurses. Entering the nursing Götaland with approximately 16,000 employees who profession is described as a reality shock, and theoreti- are divided into 120 departments and located at four cal education is difficult to address in a practical setting. different in the Gothenburg area, namely, Nurses acquire nursing knowledge and skills (knowing Sahlgrenska Hospital, Eastern Hospital, Mölndal Hospital how) by learning the theory (knowing that) that is devel- and Högsbo Hospital. Sahlgrenska University Hospital oped during nursing education and later in clinical prac- offers employed newly graduated nurses a structured tice according to a nurse’s personality. This transition is introduction (basic year) with supervision, mentorship described in the five stages of novice, advanced begin- and clinical education at two work places (surgical, ner, competent, proficient and expert [5]. Being trans- medical department). The medical department where formative, integrative and representative, competences the study was conducted includes two (medical ward, include support, confirmation, participation, and prob- emergency unit) units. lem solving in the daily work as a nurse [7,8]. Moreover, a high quality of care focuses on patients’ medical issues Design and their experiences, as well as resources regarding This study used content analysis, a qualitative meth- health and well-being [10]. Although nursing is unpre- od that involves an inductive approach, to increase the dictable and demanding due to a variety of health prob- understanding of newly graduated nurses’ voices, views lems and patients of all ages, teamwork is needed to and thoughts about their introduction to the nursing provide a high quality of care [11]. According to the re- profession. This method reveals conflicting opinions search [12], newly graduated nurses’ experience emer- and unresolved issues regarding the meaning and use gency care as challenging, exciting and intimidating due of concepts, procedures and interpretation. Content to rapid changes with a high degree of problem solving. analysis illustrates the use of several concepts that re- In addition, newly graduated nurses’ experience anxi- late to research procedures to achieve trustworthiness, ety and reduced self-confidence regarding their limited credibility, dependability and transferability [18,19]. A knowledge and skills; therefore, continuous supervisors qualitative research design that relies on trustworthi- and/or mentors are significant to the introduction to the ness, transparency, verification, and reflexivity and that nursing profession [13]. However, experienced nurses is “information driven” can be helpful when developing (supervisors) use different skills (tacit knowledge) in insightful and appropriate interpretations within nurs- nursing, which can be confusing and can cause uncer- ing [20]. An inductive methodological approach was tainty among newly graduated nurses. Therefore, newly used to analyze the data based on the content of newly graduated nurses who work in a rapidly changing work graduated nurses’ thoughts and experiences regarding environment need mentorship and long-term support entering the nursing profession [18,19]. that provide conditions to increase their self-confidence and independence [6,14]. Data collection The expectations regarding newly graduated nurses’ A small convenience sample that is appropriate clinical skills and responsibility to handle patients con- for qualitative methods was used [20]. The inclusion tribute to occupational stress. Interprofessional team- criteria for participation were registered nurses over work is therefore emphasized to manage a high quali- the age of 18 years with the ability to understand ty of care [15]. However, teamwork requires a healthy and speak Swedish and involved the basic year (4-12 work environment [14], i.e., a supportive culture and month experiences from June 2017-March 2018) in a opportunity for reflection at work [13,16]. Therefore, medical department (medical ward, emergency unit) at the transition from student to is chal- Sahlgrenska University Hospital. Two of the authors (EI, lenging as theoretical knowledge is translated into prac- JV) sent out an inquiry and an informational letter by tical settings. For this reason, the current study intends email regarding the aim, confidentiality and voluntary to broaden the knowledge regarding the introduction participation to all employed newly graduated nurses (n to nursing. = 11) in the department consistent with the inclusion criteria. Two of the authors (EI, JV) contacted these Aim nurses (n = 11) by text messages (mail, mobile phone) The aim of this study was to describe newly and informed them about the current study. Two graduated nurses’ experience of introduction to a reminders (text messages) were sent out, and the first five nurses who were interested in participation

Ingvarsson et al. Int Arch Nurs Health Care 2019, 5:119 • Page 2 of 8 • DOI: 10.23937/2469-5823/1510119 ISSN: 2469-5823 were included. The ethical guidelines for human and ries were identified and grouped related to the codes; social research were considered throughout the study and 5. One category was identified (managing uncer- [21]. The data were collected in March 2018, and tainty in the nursing profession) and three subcatego- the participants (n = 5) were informed about the aim ries were grouped (being humble as a newly graduated and study procedures; confidentiality was assured nurse, being adaptable as a newly graduated nurse and before the interviews were carried out, which were being a staff member instead of a nursing student) to all conducted in Swedish and started with background respond to the experiences of introduction as a newly questions, including questions regarding age, education graduated nurse. and personal experience with healthcare. Furthermore, The findings are illustrated with quotes. the data collection focused on five perspectives, namely, the introduction to nursing, supervision, mentorship, Ethical considerations work environment and future aspects regarding the Ethical approval and permission for the study were introduction to nursing. The interviews started with obtained from the manager of the medical department “Tell me about your experience of introduction at your at Sahlgrenska University Hospital and from the first- work place?” Based on the answers, related questions line managers in the emergency and medical ward (the were asked. Examples of situations such as positive and participants’ workplace). No ethical approval was used negative aspects of the introduction were explored, due to Swedish rules and guidelines regarding student and clarifications and further elaborations were made. theses and/or projects regarding quality improvement The interviews lasted between 10 to 25 minutes and that have no negative effects on participants [21,22]. were performed individually by two of the authors (EI, Respect for the individual nurse was a main concern JV); all interviews were recorded and then transcribed during the study. All nurses were informed (verbally, verbatim. The participants were registered nurses (age in writing) and confirmed by a signed consent form. 24-42 years) with experience as an RN (1-9 months) and Moreover, no names were used, and the results are earlier experiences of health care (0-24 years). described in categories without identifications. Respect for the participants’ integrity and autonomy was thereby Data analysis shown [21]. The interviews were analyzed by using manifest qualitative content analysis [18,19] to interpret the Findings meaning from the data content to address trustworthi- The data analysis generated one main category, ness [20], with examples drawn from the area of newly managing uncertainty in the nursing profession, which graduated nurses’ experience of their introduction to includes the three subcategories of being humble as nursing in a medical department. Written words were a newly graduated nurse, being adaptable as a newly the basis for the analysis, which was performed in the graduated nurse and being a staff member instead of following steps (1-5) which are described in Table 1 a nursing student. These categories are presented in as examples of the analysis process: 1. The transcripts Figure 1. were read and reread to obtain an understanding of and familiarity with the text; 2. Meaning units (words, Managing uncertainty in the nursing profession sentences or paragraphs) that corresponded to the con- The main category of managing uncertainty in the tent areas were selected by using an inductive approach nursing profession is described as a transition from concerning (a) the demands and (b) uncertainty; 3. Each nursing student to registered nurse. The newly grad- meaning unit was condensed into a description of its uated nurses emphasize the significance of individual content and labeled with one of 248 codes for example support by experienced nurses to manage the demands less experienced, limited responsibility; 4. Subcatego- within the nursing profession and the routines at the

Table 1: Examples of the analysis process.

Meaning unit Condensation Code Domain Subcategories Category So, you were not a perfect Not a perfect nurse ... Less Demands Being humble Managing nurse when I walked next .. like a student experienced as a newly uncertainty in the to saying it was like I was a graduated nurse nursing profession student in semester 6 ... but I still had to do everything, Do everything, Limited Uncertainty Being adaptable Managing but it's always somebody who someone who controls responsibility as a newly uncertainty in the controls everything just like .... felt like a student graduated nurse nursing profession practicing my drug divisions and everything ... so that, because I did not have it before, I felt like a student in one and one half week ...

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Being humble as a newly graduated Humble nurse

Being adapable as a newly Adaptable graduated nurse

Being staff member instead of a Staff nursing student Managing uncertainty in the nursing profession

Figure 1: The category and subcategories generated in the results. work place. The development of nursing skills during to manage as a nurse, I wish to do well and be as good the introduction is influenced by the work environment as all those nurses who have worked for several years. I and the specific supervisors’ way of facilitate nursing at thought that I have to fulfil this entire requirement from the ward. Moreover, the participants identify the sig- day one... that this were the expectations….thankfully I nificance of including organizational perspectives ac- have received a lot of support and feedback. (Nurse 3) cording to the structure of the introduction such as the timetable, tasks regarding nursing responsibility (num- However, the participants describe anxiety from ber of patients) and level of care (complex need) in col- making mistakes due to limited nursing skills that laboration with the team. The above factors influence need to be performed in a rapid and changeable work the participants’ professional growth such as increased environment with a high workload. Therefore, they independent work, especially at the emergency unit. identify the significance of individual introduction to their new professional role to ensure patient safety. Being humble as a newly graduated nurse Being humble is emphasized in a variety of tasks such as patients with a complex diagnosis. The participants The subcategory of being humble as a newly gradu- address a need for opportunities to discuss the content ated nurse is described as coping with the requirements and assignments with experienced colleagues, which is and demands of the nursing profession while being su- illustrated as pervised by experienced colleagues. As novices, they emphasize humbleness as crucial to handle the high … maybe it’s just that mentoring is very important, I demands (from themselves and other people), because would like to feel like a newly graduated nurse and get their skills cannot be compared with an experienced support by talking with you, as a mentor. (Nurse 2) nurse’s knowledge and skills: Moreover, the nurses were satisfied with the So, you were not a perfect nurse when I walked next supervision that they received especially in difficult to saying it was like I was a student in semester 6 (last tasks such as medical devices that they have no previous semester within the nursing programme) (Nurse 1) experience in. Nevertheless, the participants were eager to start working after graduation and indicated The introduction ranged between two (emergency that they expect themselves to do their very best. In unit) to four weeks (medical ward). However, the par- addition, the participants emphasize the significance of ticipants expressed a need for improved reconciliation personal responsibility for increased learning in specific because the quality of the introduction was influenced situations, which is clarified in the following quote: by variations of time, personality (supervisor) and work- I was very excited about this responsibility, and you load. They describe that the medical department is la- want to perform and want to be as good as all those bor-intensive, with challenging, complex care situations. nurses who have worked for several years… it’s in some The participants indicate the importance of humility in way your requirement ... I thought that was what I their new occupational role although nursing never be- expected when I worked; however, I have received a lot comes perfect. Therefore, they argue that newly grad- of support and feedback. (Nurse 3) uated nurses need to lower their own demands by re- Accordingly, the nurses describe the significance minding themselves that they are novices and cannot of being humble as a newly graduated nurse with the be compared with experienced colleagues. opportunity to influence the introduction of nursing I struggled a lot... over the responsibility that you have activities and routines at the workplace.

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Being adaptable as a newly graduated nurse tation system (medical records) to adapt to. They argue that being adaptable requires improved collaboration The subcategory of being adaptable as a newly (dialogues) between new and trained staff members graduated nurse is described as the conditions for regarding routines and equipment at work. In addition, confidence at work supported by a healthy work the participants were uncertain regarding the content environment, i.e. helpful and friendly staff members that involved participants in different daily activities. The and tasks of a supervisor compared with being a men- participants experienced a healthy work environment in tor; some participants believed that these were the terms of limited work tasks provide by the supervisor. To same, i.e., one person with two different names. The be adaptable as newly graduated nurses is described as content of mentorship was unclear to them due to un- being curious and committed in different daily activities planned and unorganized meetings during the introduc- that take place at the ward. They stress that staff tion phase; for this reason, they needed more informa- members encourage them to be involved in different tion regarding how they as newly graduated nurses can nursing activities, which require adaptation. The nurses use mentors after the introduction in the rest of the ba- felt that it was easy to receive support and respond to sic year. Therefore, being adaptable was accomplished questions, which is clarified by the following quote: with a healthy work environment. “Ask for help 10 times if you do not understand Being a staff member instead of a nursing student (supervisor)” What do you think about this? You have The subcategory of being a staff member instead to ask; otherwise, you get anxiety and very hysterical. of a nursing student is described as the adaptation (Nurse 1) to the nursing profession in collaboration with the The participants emphasize that all staff were helpful involved team members, i.e. personal development in regardless of healthcare professionalism. For example, being confident as a registered nurse. The participants they felt included because their colleagues invited identify the transition from student to registered them to participate in various activities at work such as nurse as a major step, which is developed during the drug administration and demonstrations of new care introduction and the basic year that is included at the procedures. One nurse explains the benefit of getting two clinical work places. They indicate that they have help as to manage a gap between nursing education and clinical settings through vocational education including What has been good is that everyone (on the team) is increased nursing responsibility. The participants also like a tiny supervisor who helps and tells different things. address variations in patient responsibility; some nurses I think it’s quite important that all persons join in the well manage the increased patient responsibility due introduction ... it is not certain that the supervisor thinks to prior vocational education from earlier personal of everything … then it’s good that others jump in and healthcare experiences, while other nurses state that explain how they think, not just the person in charge of they were quickly thrown into nursing procedures the intro; it could be the person next to you ... (Nurse 5) with many patients to take care of. To improve patient Being adaptable as a newly graduated nurse was safety, the participants emphasize ongoing dialogue identified as a tool for the best possible outcome between novice and experienced nurses regarding the regarding the introduction phase. The participants responsibility to facilitate the transition to being a staff received support from their supervisor according to member. Moreover, these transitions in nursing were the introduction plan, which contributed to personal delayed due to limited equipment such as the available development within nursing. A helpful, supportive computers for reading and documenting nursing and instructive supervisor for specific needs in nursing activities, which is why the participants felt unsure and the responsiveness of staff members facilitate regarding nursing activities concerning medical records. professional growth in nursing, why adaptation is significant: The nurses’ described that the introduction focus- es on clinical support; however, they emphasized that but I still had to do everything, but it’s always mental support was equally important to them to con- somebody who controls everything just like practicing quer a new working situation with a new professional my drug divisions and everything ... so that, because I role as registered nurses. Moreover, barriers such as a did not have it before, I felt like a student in one and one shortage of nurses caused problems to the planned in- half week (Nurse 2) troduction, which delays personal development in being Moreover, the participants emphasize that system- confident as a registered nurse. The participants indi- atic introduction with standardized (nursing activities) cate that a high workload among staff members creates and individualized (adaptation to earlier experience) uncertainty due to limited possibilities for reflections content improves patient safety in the medical depart- with colleagues; however, they emphasize that patient ment. However, the nurses who were educated outside safety was always the priority of all nursing activities at the local university city indicate their increased need re- the unit. Moreover, the nurses argued that unfamiliar garding new routines at work, for example, a documen- terms (diagnosis, medical records, and treatments) and

Ingvarsson et al. Int Arch Nurs Health Care 2019, 5:119 • Page 5 of 8 • DOI: 10.23937/2469-5823/1510119 ISSN: 2469-5823 routines influence the transition to be a nurse. There- this reason, teaching and educational supervision are fore, being supervised in clinical practice was beneficial considered to be least important among trained staff and increased their knowledge and skills in their daily members. work. The participants discuss the pros and cons of be- By using the European Federation of Nurses (EFN) ing taught by different team members as follows: Association guidelines for the implementation and I thought it might be a bit worse, and then you had to recognition of professional qualifications [7], and the start over every time you got a new supervisor, because International Council of Nurses’ (ICN) Code of Ethics they don’t really know how much you know or what you for Nurses [8], the content of the introduction could have done before. (Nurse 4) be standardized in nursing. However, the introduction to nursing also needs to be individualized according The nurses indicate that high-quality supervision to specific nurses’ earlier experiences. Therefore, includes one to two supervisors who share the vocational improvement in the basic year for newly responsibility regarding vocational education, which graduated nurses is suggested to include supervision extends the perspective of newly graduated nurses by (daily/weekly) at the ward by one to two supervisors showing them different ways of working. Moreover, with team members, regular meetings (weekly/ the participants argue that being a registered nurse is a monthly) with a mentor who works at another ward natural topic to discuss during their mentorship within and group seminars with specific topics that are the basic year in transitioning from novice to expert. In relevant to the work place (monthly). By using a summary, being a staff member was accomplished with structured introduction according to the EFN [7] and supportive teamwork. ICN [8] guidelines combined with a consideration of the Discussion specific care unit routines and specific nurses’ needs according to their background facilitate a healthy work The aim of this study was to describe newly environment with decreased occupational stress. This graduated nurses’ experiences of their introduction to approach is consistent with Patterson, et al.’s [12] point nursing. The main result regarding entering the nursing of view that enlarging the introduction (time) at the profession was expressed as managing uncertainty in ward level facilitates self-confidence in complex nursing the nursing profession. Therefore, introduction and situations, such as drug administration and critical care, mentorship during the first year in nursing are crucial and improves nurses’ work environment and patient to provide a high quality of care. Newly graduated safety [25]. nurses need support to facilitate their transition from student to registered nurse [23]. According to Benner Moreover, experienced nurses improve high- [5], newly graduated nurses are challenged during quality care by problematizing content and engaging their first year in nursing, and theoretical knowledge is in challenging tasks that facilitate newly graduated performed through behavioral attributes and advanced nurses to manage new assignments at work in a practice skills. Moreover, Numminen, et al. [24] indicate satisfactory manner [28]. Therefore, an introduction that the implementation of new evidence-based that is led by experienced nurses is crucial during the knowledge starts in nursing education based on the first year of nursing. Newly graduated nurses need to latest science, which is why it is significant that newly be challenged. However, being completely prepared in graduated nurses are supported at work. However, nursing may never occur because new challenges arise some limitations involve nursing education (theory within an unpredictable and complex care environment. versus practice), shortages of nurses’ influence, and a According to Clipper and Cherry [25], it is common for high workload with the responsibility for many patients nurses to make mistakes at the beginning due to a lack of with complex care needs; in this way, nurses’ work support; therefore, mentoring is a tool for patient safety. environment delays the transition into the nursing This result is consistent with the research’s [29-31] profession [3,15,25]. In addition, Fukada [26] describes explanation that structured mentoring with committed that nursing competency also includes the ability to role models (supervisors/mentors) is crucial. Moreover, understand people and healthcare situations by using because of the complexity and variety of health care, assessments, communication and clinical judgement. nursing education has limitations in preparing for all Therefore, nurses need the ability to provide person- situations. This finding is consistent with Numminen, centered care in an interprofessional collaboration by et al. [24] who emphasize that newly graduated nurses focusing on resources and partnerships in health care express anxiety and insecurity due to their expected [10,27]. Supervision within the team contributes to competence in nursing. Therefore, integrated nursing safer and less stressed nurses especially when ethical education that involves a collaboration with university dilemmas are discussed, and professional development and clinical settings, such as quality improvement influences high-quality nursing. However, Lallo, et al. and/or a Bachelor’s thesis, facilitate evidence-based [9] argue that a high quality of care follows general nursing in relation to lifelong learning for professional principles of assessment (standardized) more than development, i.e., theoretical knowledge and practical research methods (theory in nursing education); for skills. Therefore, a basic year [32] at the ward level is one

Ingvarsson et al. Int Arch Nurs Health Care 2019, 5:119 • Page 6 of 8 • DOI: 10.23937/2469-5823/1510119 ISSN: 2469-5823 way to facilitate the transition to become a registered expert nurse. Moreover, mental support, especially nurse. during newly graduated nurses’ first-year experienc- es, decreases their anxiety regarding being insufficient The research [31,33,34] shows that mentorship and alone at work. Therefore, person-centeredness en- (over time) with trained mentors predicts and prevents sures that the staff (as well as the patients) are capable mistakes in emergency care; that is, clinical support that persons with resources to use in health care such as a uses case management contributes to an improvement healthy work environment. in novice nurses’ critical thinking. According to Strauss [35] and Wilkinson [36], the introduction develops Conflicts of Interest critical thinking, clinical assessment and prioritization, The authors declared no potential conflicts of interest crucial skills to enable adaptation, reflection and with respect to the research, authorship or publication feedback in a new professional role with a high workload, of this article. and new routines and skills. To facilitate this transition, support is needed within a healthy work environment Acknowledgements [37-40]. This finding is consistent with Benner’s [5] idea We thank newly graduated nurses at the Medical that vocational education that is performed by helpful Department, Sahlgrenska University Hospital who par- and positive colleagues contributes to decreased ticipated in the study and the University of Gothenburg demands. 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